Healthcare: A back up industry

Healthcare: A back up industry

Examples of system failure are littered around the medical field and often disguised as professionalism or better yet heroism. “One resource seems infinite and free: the professionalism of caregivers”, says an opinion piece published in The New York Times. The article goes on to say that an overwhelming majority of health care professionals do the right thing for their patients, even at a high personal cost. Noteworthy is the availability heuristic that comes into play. “Of course they should work in favor of their patients, no matter what, isn’t that why they chose the medical profession!?”, you ask. They sure did. A lot of why you believe that medical professionals must go out of their way to help patients can be explained by what news you are being exposed to these days. The availability heuristic! That kept aside the gist of the article can roughly be summed up in the following excerpt

“Counting on nurses and doctors to suck it up because you know they won’t walk away from their patients is not just a bad strategy. It’s bad medicine. This status quo is not sustainable — not for medical professionals and not for our patients.”

I invite you to, for some minutes, drop all the preoccupation and think about it logically. I have, time and again, submitted myself to the idea that empathy and not logic is the best way to get my point across. But today, let us first think about some pertinent analogies.

As we anticipate the dreaded tsunami of COVID-19, many governmental healthcare institutes are sending out a notice for recruiting doctors and nurses for a certain time. My sister who is a nurse said, “Why do they have to make it sound like we are disposable?”. To which, I wittingly replied, “ Well they are probably looking for paid volunteers.” But the same recurring theme covers the core of our conversation. We simply were treating healthcare as a per-need industry. When the reality is, again, a contrasting opposite. Indeed, healthcare is a backup industry. You do not wish to use it when things are going smoothly. The healthcare system of any country should stand on its mighty ability to deal with crises.

Most other industries can either do with the number of people already in the industry or have to let go of people they already had, during a disaster. That is a contrasting opposite to the healthcare industry. Every time the health of the public is threatened we start to search for volunteers and temporary hires. I argue this is because the healthcare industry is ruled by businesses in the most powerful countries. To the point that the notion of just enough or even fewer doctors working in a setting is looked upon as a heroic measure. I don’t suppose you would say. “Oh! That busy bank has only one teller, and she also works as a receptionist. How heroic of her!”, do you?

There are reserves in almost every industry. Take transportation as another example: I visited Kathmandu on a night bus during my vacation as a child. My dad introduced me to two men. Both of them were drivers. I was taken by surprise when I found out the bus only had one steering wheel. “What would the other driver do!?”, the inquisitive child in me asked. My dad was semi-asleep when he answered, “They will drive for the whole night. Don’t you think they need to rest?”. I sure do Dad, I sure do!

In aviation, the first officer (FO) is the second pilot (also referred to as the co-pilot) of an aircraft. The first officer is second-in-command of the aircraft to the captain, who is the legal commander. In the event of incapacitation of the captain, the first officer will assume command of the aircraft. A second officer is usually the third in the line of command for a flight crew on a civil aircraft. Usually, a second officer is used on international or long haul flights where more than two crews are required to allow for adequate crew rest periods.

There have been some examples of what would be analogous to a natural disaster in other industries. Let us take some economic ups and downs as examples. Remember, India demonetized Rs. 500 and Rs. 1000 notes? Bankers had to work extra hours to make sure the undertaking completed in due time. They, of course, were paid an extra allowance for that. Interestingly they did not have to open up more positions for the work to be carried out. Remember the great economic recession? It “forced” business owners to let go of their employees. Not recruit more!

I vividly remember feeling proud of one of my seniors who was portrayed as an ideal healthcare worker. “He was arranging the medicine cabinet when we visited him”, one of my professors boasted. I felt not only proud but a desire to be at his place and do as he did one day. Today I understand that 1) he could be doing something way more productive and 2) what my senior was doing when my professor reached there was a clear example of a system failure.

Let me give you an example of my intern year to demonstrate the lack of consideration of the human element in designing healthcare systems. I had to take leave for some days. It was the flu. I understand that the coronavirus situation has alchemized the glory that flu deserved all along, but those were different times. I had a severe sore throat and my body ached like some virus was gnawing on my bones. I remember feeling very guilty about being ill because while I was sniffing Vicks and popping paracetamols in the hostel. My friends (fellow interns) were working their asses off. But when the system was designed, did no one think that someone might get sick? I mean, we work around infections every day. C’mon system designers, that is blindness, not just shortsightedness. The irony is: we are in an industry where we boast about our ability to empathize with human pain, suffering, and ill-health.

Human development has been punctuated by disasters of some sort, time and again. It is almost comical that we haven’t learned our lessons and that harrowing circumstances have to keep reminding us of the need for preparedness. It almost feels like I am writing a reminder the second time. After I failed to follow through my previous reminder. For me, the first time was the Nepal earthquake 2015. I am sure you have your own first time. I can only speak of the healthcare industry because that is what I have been fortunate enough to see closely. I am sure preparedness means different things in different settings. For healthcare, it means 1) taking into account the human element and 2) realizing that healthcare is a backup industry.

Recent Blog Posts By Sajan Acharya

Illness Narratives In Global Health

Storytelling is a powerful tool that allows us to relate to one another across borders, cultures, and experiences. It is a significant aspect of global health. Images associated with international health are those of pediatric patients in low and middle-income countries (LMICs) with descriptions of ailment or news stories on television of an outbreak in a faraway country. These stories capture our attention and allow us to process situations far removed from ours. While stories allow us to communicate the urgency and extent of international health topics, there are challenges associated with illness narratives. It is important to examine how stories are told in medicine, and specifically in global health. It is critical to question who tells stories, how they’re told, and what their impact is. These can be stories of individual patients in a country, medical aid organizations, or even stories of a country’s health infrastructure.

A recent Lancet essay titled “Global Health 2021: Who tells the Story” examines the role of journals when it comes to research in academic global health. The essay cites data showing a lower number of publications authored by those affiliated with or came from LMIC in The Lancet Global Health(1). Here, the authors reflect on how, as a London-based global health journal, they need to examine the narration disparities. They note that an imbalance in authorship is a symptom of an imbalance in power when it comes to academic global health.

This essay was in part motivated by a crucial article by Seye Abimola and Madhukar Pai. In their article examining the decolonization of global health, Abimola and Par state “even today, global health is neither global nor diverse. More leaders of global health organisations are alumni of Harvard than are women from low-income and middle-income countries. Global health remains much too centred on individuals and agencies in high-income countries (HICs).”(2) This important point highlights the distance between the subject of stories and those who tell them. This can limit diversity in perspective while taking away ownership of stories from those who experience it.

An article looking at illness narratives in an outbreak reported that when it comes to Ebola, Zika, and SARS, marginalized communities often bear the burden of disease while their account of illness is often neglected. The authors state, “regardless of income setting, there is a need to give voice to the most marginalized communities during an epidemic.”(3) This point on narration should extend beyond authorship in research to include news coverage of global health events. The way the Ebola outbreak and even early days of COVID pandemic were portrayed are examples of the dangers associated with lack of nuance in the way global health topics are discussed in the media.

Inclusivity of illness narratives around global health can allow us to avoid pitfalls that lead to widespread misinformation and discrimination. In addition to examining who tells the story, it is also important to explore how stories are told. An essay highlighting the challenges of storytelling in medicine notes that at times the trauma of subjects has been exploited by international charities. The article states the importance of communicating stories in a way that does not “feast on the trauma of others”(4). 

At the core of his argument is the need to examine how we communicate the stories of others. As described above, allowing locals to tell stories regarding their experience of illness, outbreaks, and research can help us deal more carefully with the associated trauma. Stories told without careful consideration can lead to widespread misinformation and potentially harmful generalizations. As we move towards examining how we improve global health delivery, it is critical to explore how we can improve the stories we share. In order to create a better system to communicate important global health topics, it is imperative to challenge the ways we receive information constantly.

This will broaden our understanding of complex issues and allow us to consider alternative solutions.

To this end, the following five questions should help us navigate the challenges of global storytelling. These questions are suggested to help guide our approach towards a more

  1. Has the subject given informed consent to tell their story?
  2. How is the story presented?
  3. Is there a way to allow the story subject to be
  4. Do the stories told reinforce harmful stereotypes?
  5. Are there negative consequences to the subject if the story is told?

References and Further Reading

  1. Health TLG. Global health 2021: who tells the story? The Lancet Global Health. 2021;9(2):e99.
  2. Abimbola S, Pai M. Will global health survive its decolonisation? The Lancet. 2020;396(10263):1627-1628.
  3. Kapiriri L, Ross A. The politics of disease epidemics: a comparative analysis of the sars, zika, and ebola outbreaks. Glob Soc Welf. 2020;7(1):33-45.The
  4. Harman S. The danger of stories in global health. The Lancet. 2020;395(10226):776-777
Cite this article as: Nardos Makonnen, USA, "Illness Narratives In Global Health," in International Emergency Medicine Education Project, April 5, 2021, https://iem-student.org/2021/04/05/illness-narratives-in-global-health/, date accessed: September 25, 2021

Compassion Fatigue in the ER and Beyond: When caring leads to an inability to care

compassion fatigue

That doctor was horrible! How could she be so rude? She’s a doctor after all.

Anonymous

What is Compassion Fatigue?

In December 2020, a relative had just been at the hospital with my grandmother recently diagnosed with pancreatic cancer. The oncologist on site had been described as rude and inattentive to my grandmother’s needs, or so I was told. Due to COVID-19, the number of visitors had been limited in the hospital. Everything I heard regarding the quality of care my grandmother received was through word of mouth. Initially, I was furious. Then, I stopped and pondered the situation, leading to a realization and inspiration for this article. Perhaps the doctor was not as rude as she was made out to be. Perhaps, she was undergoing compassion fatigue, the emotional and physical exhaustion leading to a diminished ability to feel compassion for others. Compassion fatigue is often due to burnout and stress, something which I believe to be more prevalent during the COVID-19 era. However, compassion fatigue is not a new term. I first heard it during my internship with the Emergency Department at Toronto Western this summer. It is only now; I am beginning to see it unfold in real life, and truly understand it. Therefore, for this article, I will discuss compassion fatigue, how to notice it, and how to prevent becoming a victim to burnout.

burn-out army
Figure 1. The Roll Call is an 1874 oil-on-canvas painting by Elizabeth Thompson, Lady Butler. The worn soldiers resonate, what I imagine to be a very burnt-out army of front-line workers during the COVID-19 pandemic.

Compassion Fatigue in the ER and Beyond?

Compassion fatigue is not unique to any one medical specialty; however, it is commonly seen in high-stress specialties where patients are normally sicker and in a more critical condition. In a study of ED nurses (Borges 2019), compassion fatigue was more prevalent in women and decreased with the increasing age of the nurse. Reasons for these trends were that women were more likely to experience their patients’ pain compared to men, and older nurses were more equipped to handle stressful situations compared to younger nurses. Gribben et al. (2019) looked at compassion fatigue in pediatric emergency medicine physicians and found burnout was the highest predicting factor in developing compassion fatigue. Interestingly, this group’s prevalence of compassion fatigue was lower compared to other pediatric specialties that followed patients longitudinally. This may suggest that the greater the relationship with the patient, the greater the impact of developing compassion fatigue; however, only one of the few papers suggested this relationship. In another study. Hooper et al. (2010), assessed compassion fatigue across multiple specialties (nephrology, oncology, intensive care, emergency medicine), and found no significant difference in compassion fatigue among these groups. While there was no statistically significant difference in compassion fatigue in this study, 82% of ER nurses reported moderate to high burnout levels, and 85% of ER nurses reported high levels of compassion fatigue.

Moreover, certain specialties were more likely to report a different adverse experience related to the job. For example, burnout was higher in intensive care doctors, compassion fatigue was higher in oncologists, and healthcare providers in the ER were more likely to report less compassion satisfaction and the pleasure of doing work. Currently, compassion fatigue is becoming a major concern in the era of COVID-19. Ruiz et al. looked at compassion fatigue, burnout, and compassion satisfaction in Spain’s healthcare workers during the COVID-19 pandemic. In this study, physicians reported higher compassion fatigue and burnout scores compared to nurses, who reported higher compassion satisfaction scores, despite reporting similar perceived stress. One explanation for compassion satisfaction in the nurses were their perceived importance during the pandemic.

Model of Compassion Fatigue

Since compassion fatigue is prevalent in medicine, it is important to understand some of the theories behind compassion fatigue and what causes it. Cocker and Joss (2016) provide one example of a model on compassion fatigue.

Model of Compassion Fatigue
Figure 2: Compassion Fatigue Model adapted from Cocker and Joss

This model encompasses many of the concepts cited in the literature regarding compassion fatigue, such as burnout, secondary trauma and compassion satisfaction. Although compassion fatigue is one definition, it is important to fully understand the concepts used in the model by Cocker and Joss (2016), to better our understanding of what compassion fatigue is and it relates to other variables encountered in the healthcare field. Compassion fatigue is the emotional and physical exhaustion, leading to an inability to feel compassion or empathize with another. Compassion Satisfaction is the amount of pleasure derived from being able to do work. Burnout occurs when an individual cannot reach their goals, leading to frustration, loss of morale, and decreased willful efforts. Finally, secondary traumatic stress arises from a rescue-caretaking response and occurs when an individual cannot rescue or save someone from harm, resulting in significant guilt and distress. Compassion fatigue can be caused when there is increased burnout or exposure to secondary trauma. While stressors can be part of the medical career, especially in the ED, compassion fatigue does not always need to become a consequence. Compassion satisfaction can act as a mediator, thus counteracting the negative effects of burnout and secondary trauma. One mechanism for the beneficial role of compassion satisfaction is its importance for building resiliency and transforming negative experiences to positive experiences.

How to Notice and Manage Compassion Fatigue

Given the impact of compassion fatigue on a physician and their ability to care for a patient, it is important to recognize and prevent the development of compassion fatigue. Some studies (Peters et. Al, 2018) acknowledge the need for education on compassion fatigue and suggest that this needs to be implemented at the individual and institutional level. Moreover, it is essential to note that many health professionals are not aware of compassion fatigue (Berg et. Al, 2016). Two inventories which have been used to assess for compassion fatigue in the literature include the Professional Quality of Life Scale and the Holmes-Rahe Life Stress Inventory. Berg describes that while most health professionals have their own individualized ways of dealing with stress, none of the healthcare providers interviewed in his study reported receiving any training in compassion fatigue. Berg mentions that group coping and debrief sessions can be useful strategies to prevent compassion fatigue (Berg et al., 2016; Schmidt et al., 2017). Finally, other institutional strategies may include identifying employees at high risk of compassion fatigue, provision of training to identify and cope with compassion fatigue, the use of workshops to promote self-care and other measures, such as open dialogue, to validate compassion fatigue and the risk it poses to healthcare provider wellbeing (Smith, 2012).

Closing Remarks

Compassion Fatigue is real, and often insidious in the presentation. Unfortunately, the concept of compassion fatigue is not always known, and at times its presence among ourselves and our colleagues can be challenging to identify. I believe that this is a concept which must be discussed, especially with the growing demands on healthcare providers and increasing stress during the COVID-19 pandemic. Sometimes caring can have negative impacts on healthcare providers. So begs the question, who takes care of healthcare providers while they are caring for others. We are not immune to the stress that comes with our job. Importantly, we must find ways to identify and support one another to not diminish our ability to care.

Cite this article as: Brenda Varriano, Canada, "Compassion Fatigue in the ER and Beyond: When caring leads to an inability to care," in International Emergency Medicine Education Project, February 17, 2021, https://iem-student.org/2021/02/17/compassion-fatigue/, date accessed: September 25, 2021

Recent Blog Posts by Brenda Varriano

References and Further Reading

  • Berg, G. M., Harshbarger, J. L., Ahlers-Schmidt, C. R., & Lippoldt, D. (2016). Exposing Compassion Fatigue and Burnout Syndrome in a Trauma Team: A Qualitative Study. Journal of trauma nursing : the official journal of the Society of Trauma Nurses, 23(1), 3–10. https://doi.org/10.1097/JTN.0000000000000172
  • Borges, E., Fonseca, C., Baptista, P., Queirós, C., Baldonedo-Mosteiro, M., & Mosteiro-Diaz, M. P. (2019). Compassion fatigue among nurses working on an adult emergency and urgent care unit. Fadiga por compaixão em enfermeiros de urgência e emergência hospitalar de adultos. Revista latino-americana de enfermagem, 27, e3175. https://doi.org/10.1590/1518-8345.2973.3175
  • Cocker, F., & Joss, N. (2016). Compassion Fatigue among Healthcare, Emergency and Community Service Workers: A Systematic Review. International journal of environmental research and public health, 13(6), 618. https://doi.org/10.3390/ijerph13060618
  • Gribben, J. L., MacLean, S. A., Pour, T., Waldman, E. D., & Weintraub, A. S. (2019). A Cross-sectional Analysis of Compassion Fatigue, Burnout, and Compassion Satisfaction in Pediatric Emergency Medicine Physicians in the United States. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 26(7), 732–743. https://doi.org/10.1111/acem.13670
  • Hooper, C., Craig, J., Janvrin, D. R., Wetsel, M. A., & Reimels, E. (2010). Compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties. Journal of emergency nursing, 36(5), 420–427. https://doi.org/10.1016/j.jen.2009.11.027
  • Peters E. (2018). Compassion fatigue in nursing: A concept analysis. Nursing forum, 53(4), 466–480. https://doi.org/10.1111/nuf.12274
  • Ruiz-Fernández, M. D., Ramos-Pichardo, J. D., Ibáñez-Masero, O., Cabrera-Troya, J., Carmona-Rega, M. I., & Ortega-Galán, Á. M. (2020). Compassion fatigue, burnout, compassion satisfaction and perceived stress in healthcare professionals during the COVID-19 health crisis in Spain. Journal of clinical nursing, 29(21-22), 4321–4330. https://doi.org/10.1111/jocn.15469
  • Schmidt, M., & Haglund, K. (2017). Debrief in Emergency Departments to Improve Compassion Fatigue and Promote Resiliency. Journal of trauma nursing : the official journal of the Society of Trauma Nurses, 24(5), 317–322. https://doi.org/10.1097/JTN.0000000000000315
  • Smith, P. (2012a) Alleviating compassion fatigue before it drags down productivity [PDF]. Long Term Living. http://www.compassionfatigue.org/pages/longtermliving.pdf

The Unspoken Damage of COVID-19 on Spanish-Speaking Patients

The Unspoken Damage of COVID-19 on Spanish-Speaking Patients

The COVID-19 pandemic has uncovered some ugly truths about the American healthcare system. One of the ugliest is discrimination against non-English-speaking patients. This form of discrimination particularly affects native Spanish-speaking only patients (defined in this article as “Spanish-speaking patients), who comprise not only a large proportion of America’s hospital patronage but also a majority of those suffering from COVID-19.

In May 2020, as part of my Emergency Medicine residency training, I worked at a small community hospital in northern Virginia, located in an agricultural area with a large number of Central American and Mexican migrant workers. The first few days of the rotation were relatively unremarkable until the COVID-19 cases began to pour in. Most of those suffering from severe COVID-19 were Spanish-speaking patients employed at a local plant nursery where an outbreak was occurring.

I intubated a COVID-19 patient almost every day I worked there. I speak Spanish fluently, and since I was able to communicate with Spanish-speaking patients and their families, I was able to obtain consent for the procedure. I will never forget one patient who had tears rolling down his face shortly after intubation as we titrated his post-intubation sedation medications. I spoke with his son over the phone, in Spanish, who thanked me profusely and cried, worried he would never see his father alive again. He asked if he could visit his father in the hospital. He cried more when I explained the no visitor policy for hospitalized COVID-19 patients. He still thanked me.

The ER staff also thanked me, because until I arrived, few in-person Spanish interpreters or fluent Spanish-speaking providers worked there. Therefore Spanish-speaking patients consented to intubations using a phone-based interpretation service. Though The Joint Commission states that telephone or video interpretation is sufficient to obtain informed consent (especially during the COVID-19 pandemic), in-person interpretation has proved superior. Unfortunately, at this small hospital, out of necessity and due to inundation by COVID-19 victims, Spanish-speaking patients had occasionally been intubated without true informed consent. For example, I remember a case when the overwhelmed nursing staff struggled to connect to and understand the phone-based interpreter while donning PPE and equipping a Spanish-speaking patient’s room for emergent intubation, only to be followed shortly thereafter by another critical COVID-19 patient.

Despite the large number of Spanish-speaking patients receiving care in the United States, a 2016 survey of 4,586 American hospitals showed that only 56 percent offered some sort of linguistic and translation services. As a former volunteer Spanish interpreter for a university hospital, the cost is cited as the primary reason, among many. Discrimination against undocumented people and xenophobia are unstated reasons. I remember distinctly a Grand Rounds presentation about native Spanish-speaking patients in hospitals and how a Latinx pediatrician emotionally expressed how often she witnessed Spanish-speaking families receive worse care than their English-speaking counterparts. Indeed, inadequate or inaccurate interpretation has resulted in serious legal, financial, and patient safety repercussions for hospitals.

In June, I worked in the COVID-19 ICU at my residency program’s hospital. Most of the COVID-19 ICU patients had been transferred from the same small hospital where I worked the previous May. After rounds, most of my afternoon was spent contacting Spanish-speaking family members and updating them on their loved one’s condition. It was heartbreaking to tell these families that they could not visit their loved ones in the hospital. Undoubtedly, the family is incredibly important to all cultures, and particularly to central and Mexican-Americans. Sadly, these strong family ties underscore an important reason Latinx people have been disproportionately affected by COVID-19: many live in large, multigenerational family homes, accelerating virus exposure and transmission. Furthermore, many are undocumented and work under substandard conditions, with few or no COVID-19 precautions. They may also be underinsured or have no insurance or benefits like sick leave, further fueling the virus’ devastation.

When you pull the bandage off a gangrenous wound to expose the decaying flesh below, you have two options: put the bandage back on and let someone else deal with it, or clean the wound and treat it so it can heal. The COVID-19 pandemic has pulled the bandage off and exposed certain disgusting realities of our health care system – how can we as Emergency Physicians heal this wound?

We must recognize that hospital under-investment in adequate Spanish interpreters is a form of racism. Medical Spanish should be required curriculum for medical students and residents. The knowledge of basic conversational Spanish goes a long way when communicating with patients and their families. Medical Spanish is not difficult, and there are enough cognates and Latin derivatives that most people, with minimal practice, can get through history and physical in Spanish. Most importantly, hospitals should invest in full-time in-person Spanish interpreters, at the very least for the Emergency Department.

The COVID-19 pandemic has ravaged our healthcare system in myriad ways. With destruction comes the opportunity to rebuild and improve. This is one area that needs it.

Cite this article as: Sarah Bridge, USA, "The Unspoken Damage of COVID-19 on Spanish-Speaking Patients," in International Emergency Medicine Education Project, January 11, 2021, https://iem-student.org/2021/01/11/covid-19-on-spanish-speaking-patients/, date accessed: September 25, 2021

Unmasking communication during COVID-19

Unmasking communication during COVID-19

As face masks become ubiquitous in our health-care practice due to the COVID-19 pandemic, communication between the patient and health-care provider has become harder than ever before. The challenges posed by COVID-19 have highlighted various areas of deficiencies in the health care industry as well as heightened anxiety among health-care providers as well as patients. Communication with patients has become particularly challenging and ever so more important than before.

Imagine the plight of a patient struggling to breathe, being greeted by someone in full PPE, struggling to understand your muffled speech through the mask amidst the background noise of oxygen hissing through a breathing mask. Earlier, your smile would have worked to ease some of the anxiety by coming across as approachable and friendly; however, your face mask has cost you a brave soldier in your battle of gaining trust. The situation is worse in the elderly, frail, and cognitively impaired patients who may rely on lip-reading and facial expressions to communicate.

Health care workers are forced to have difficult conversations of do-not-resuscitate orders, advance care planning, and break bad news while wearing a face mask and PPE, creating a barrier for effective communication with patients and their family members.

If you have previously relied on a firm handshake and a smile to lessen the anxiety of patients but are now finding it challenging to have clear communication, here are few ways to improve communication with patients.

Unmasking communication during COVID-19
Cite this article as: Neha Hudlikar, UAE, "Unmasking communication during COVID-19," in International Emergency Medicine Education Project, August 10, 2020, https://iem-student.org/2020/08/10/unmasking-communication-during-covid-19/, date accessed: September 25, 2021

Who Takes Care of You While You Take Care of Others?

Who Takes Care of You While You Take Care of Others

The COVID-19 Pandemic has changed our lives in so many ways that sometimes it is difficult to remember how life was without all these changes. We got used to the “new normal”, which includes a constant concern about contamination, economic crisis, and isolation. When we consider emergency physicians and other healthcare professionals, technical and scientific challenges regarding the pandemic response are also added to the equation.

Recently we completed three months since the first case of COVID-19 in Brazil and, since then, more than 300.000 have been infected and at least 23.000 people have died. These astonishing numbers could be 8 to 10 times higher if it wasn’t for under-notification¹ in countryside areas. The psychological effect of these numbers can be seen every day while people try to cope with the situation, and it may be even more intense in those who are in the frontline of the healthcare system. With this in mind, the question emerges: Who takes care of you while you take care of others?

What are the major psychological symptoms we can expect in healthcare providers three months into the COVID-19 pandemic?

After 3 months of COVID-19, we are not dealing with acute and immediate psychological response anymore; this next phase can be called assimilation, where we already understand better the new workflows, protocols and forms of living. However, we are still in a context of insecurity, fear, and loss of control over things we used to know how to deal with. The major psychological symptoms that are expected and considered to be normal in this context are:2

  • Fear (of getting sick and dying, losing people, being socially stigmatized, being separated from people you care about and transmitting the virus to other people);
  • Stress reactions such as anger, anxiety, confusional states, apathy
  • The recurrent feeling of impotence, irritability, anguish, and sadness;
  • Behavioral changes: changes in appetite and sleep habits, and interpersonal conflicts

Which strategies we can use to minimize these effects?

It’s very important to understand these reactions as being normal reactions in the context we currently live in. However, that doesn’t mean there is nothing we can do to ease them. It’s very important to intervene as early as possible as a way to prevent the chronification of those symptoms and progression to psychological disorders. Here are some strategies that can help2:

  • Recognize these feelings and accept them as real and valid; try to talk about them with people you trust
  • Think back to the strategies and tools you used in moments of crisis in the past. When it comes to dealing with difficulties, everybody has some preferred methods, which were tried and worked. Resume those actions that have worked for you and try to find ways of applying them to this new context
  • Keep your social network active by establishing -even if virtual- contact with family, friends, and colleagues,
  • Avoid watching, reading or listening to news that makes you feel anxious or distressed; look for information only from reliable sources
  • Avoid using alcohol and drugs as coping mechanisms
  • Ask for help if you find your strategies inefficient

There are lots of health professionals who are self-isolating from their families to prevent “bringing the enemy home”. How can self-isolation affect our mental health?

Isolating from family and friends means physically isolating from your support network. It’s relevant, in this context, to understand that physical isolation doesn’t mean affective and emotional isolation. As said before, it’s important to find new ways to be present in people’s lives and keep the social network active. Maintaining these contacts is also a way to ensure that when you leave the hospital and arrive at your rest place, you can actually disconnect from the routine and difficult times by talking to family members and listening about their day, their stories, and so on. In this moment of isolation and fear, we also witness the stigmatization of healthcare professionals3. People can direct their feelings of fear and uncertainty at health professionals, potentially causing behaviors of avoidance, rejection, aggressiveness and violence. If you find yourself in this situation, it’s key to understand that these reactions are not directed towards you personally, but to the global state of insecurity and fear, we are currently living.

Have you seen any changes in the problem-solving and decision-making capabilities of the physicians in the ED due to the stressed environment?

Interpersonal conflict, due to constant changes in protocols and workflows is expected in times of crisis and might be affecting problem-solving and decision-making processes. Here are some strategies to prevent it:

  • Try to maintain a supportive work environment, including designated spaces to eat and rest
  • Have moments to let the team talk about their mental state to help to develop a sense of community
  • Alternate workers between activities of high and low attention and tension, if possible,
  • Recognize effort made and encourage mutual respect among professionals
  • Map and disseminate mental health care actions. Even if most workers will not need individual assistance, knowing that there are services that they can rely on when needed makes them feel supported

Finally, do you have any special tips for emergency physicians who are in the frontline against COVID-19 at this moment?

It’s important to know and to understand when the frequency and intensity of the normal symptoms indicate that you should see a specialized mental health professional.2

  • Persistent symptoms
  • Intense suffering
  • Risk of complications, especially suicidal ideation and substance abuse
  • Significant impairment of social and daily functioning
  • Significant difficulties in family, social or work life
  • Major depression, psychosis, and PTSD are conditions that require specialized attention

We know that healthcare workers bear considerable suffering and symptoms, but usually, this group of people refuses to seek or receive help. Among others, the main reason is that having difficulties to deal with all the emotional demands is -wrongly- seen as a sign of weakness or incompetence. At this moment, it’s more important than ever to understand that we can only take care of others if we, first, take care of ourselves. And taking care of our mental health is as important as our physical health to be at the front lines of COVID-19 response.

Gabriele H. Gomes

Psychologist, current Critical Care & Emergency Psychology Resident at Hospital de Clínicas de Porto Alegre (HCPA)

References and Further Reading (Portuguese only)

Cite this article as: Arthur Martins, Brasil, "Who Takes Care of You While You Take Care of Others?," in International Emergency Medicine Education Project, August 5, 2020, https://iem-student.org/2020/08/05/who-takes-care-of-you-while-you-take-care-of-others/, date accessed: September 25, 2021

COVID-19; Reflecting on a Globalized Response

COVID-19; Reflecting on a Globalized Response

As I write this is, it has been 200 days since the first reports in China came out regarding an unspecified viral illness in Wuhan, China. What is now the pandemic of COVID-19 has spread around the world, and in history books and our collective memory, the year 2020 will forever be closely associated with this virus. There have been nearly 14 million confirmed cases around the world and nearly 600,000 known deaths from COVID-19. Some countries have done incredibly well with containment measures, while others continue to see case counts grow every day.

It has been fascinating to see how the outbreak has had different impacts in communities around the world, including how local and global responses have efficiently controlled or been unable to contain this novel public health problem. Prevention and mitigation strategies continue to form the foundation of public health management of this outbreak. The capacity for any country or locality to provide the most invasive supportive care is widely variable, and even when it is available mechanical ventilation is certainly not a panacea as COVID-19 case-survival rates in those being mechanically ventilated have been low (from 14% to 25%).

At the core of the variable outcomes seems to be a mix of sociological issues: a mix of personal beliefs, geography, politics, socio-economics and health infrastructure which lead to vastly different outcomes around the globe.

The accumulation of more epidemiological data over the past 200 days has improved our collective understanding of the COVID-19 virus, as today we have improved models and a better understanding of the rates of asymptomatic carriers (estimated at 40%) and mortality rates (1.4%-15.4%). Yet still, uncertainties and local variability (even within countries) have made an accurate calculation of the COVID-19 basic reproductive number (R0; the number of people who are infected by a single disease carrier) difficult. In the early stage of the outbreak in Wuhan, R0 calculation ranged from 1.4-5.7, and some have suggested that instead of single R0 value, modellers should consider using ongoing contact tracing to gain a better range of transmissibility values.

We have seen how prevention strategies such as hand-washing, face-masking, and physical distancing can impact local and disseminated disease spread. While many communities have come together through a collective approach to lock-downs and universal masking measures, other localities have struggled to get adequate levels of citizen compliance. Others have struggled with obtaining testing supplies. Certain political systems allow for streamlined and unified directives while others have made it difficult to provide adequate centralized coordination.

As the COVID-19 pandemic has spread to almost every country in the world, outbreaks are smoldering in much of the global south. While the United States continues to see rising numbers of cases with numerous states confronting ongoing daily record high incident cases, other countries such as Brazil are seeing similar upward trends. At the global level, the curve of daily incident cases seemed to have “flattened” and held steady through much of April and into May with aggressive seemingly worldwide measures. However, since the last days of May, global incident cases have been again steadily increasing. This is likely due to a variety of reasons but is linked, at least in part, to efforts to reopen economies and return to pre-pandemic routines and lifestyles.

covid-19 daily cases
Source: Johns Hopkins University Coronavirus Resource Center https://coronavirus.jhu.edu/map.html, accessed July 17, 2020

As an American citizen and a physician with training in public health, it has been both interesting and frustrating to see the how some countries (including my own) have had deficiencies in dealing with testing and basic prevention (such as mandatory universal masking). While I don’t want to engage in political rhetoric or cast blame in any one place, I do think it is instructive to point out that in the United States (or anywhere else for that matter) the sociological factors of personal preferences and autonomy, geography, and local politics have had an overwhelming influence in determining the progress of the pandemic.

Quarantining has always been a unique problem that sits at the intersection of personal autonomy and communal wellbeing, and is implemented and respected by citizens in different ways around the world. It would seem, at least anecdotally, that cultures with an emphasis on personal independence and autonomous choice have had greater difficulty with containment or in obtaining high levels of compliance with masking and distancing measures, even when compared to other localities with similar socio-economic situations.

These sociological factors are key to responding to and managing any epidemic health concern. We have come to see that in our globalized world, our ability and desire to work together towards a common goal, even at the cost of personal sacrifice, will determine our ability to control both the COVID-19 pandemic and the next health crisis of the future.

Public health education and communication, it would seem, is at the crux to getting collective buy-in and global participation.

Unfortunately, as with so many things these days, such issues can be easily politicized and cause fractured and disparate approaches to response. In our globalized world, this coronavirus outbreak is unlikely to be the last public health crisis we must face as a worldwide community.

As thoughts turn towards what is to come, from vaccine development and distribution to numerous long-term economic impacts, we are not nearing the end of this outbreak yet.

The incidence curve is growing, and there is much work left to be done. My hope is that as we move into the second half of 2020, our global community can continue to find ways to improve communication and coordination in order to come together to approach and control this pandemic collectively. The fate of this outbreak, and likely the next, hangs in the balance.

Cite this article as: J. Austin Lee, USA, "COVID-19; Reflecting on a Globalized Response," in International Emergency Medicine Education Project, August 3, 2020, https://iem-student.org/2020/08/03/covid-19-reflecting-on-a-globalized-response/, date accessed: September 25, 2021

The Kawasaki Disease Enigma Continues 150 years Later

kawasaki disease

Kawasaki disease (KD), or mucocutaneous lymph nodes syndrome is an immune-mediated inflammation in the walls of medium-sized arteries throughout the body. It’s complications result in the coronary arteries expanding, heart attacks, and premature death.

As the leading cause of heart disease in North American and Japanese children, KD continues to bewilder clinicians and researchers – even in the midst of a global pandemic. Possible links to SARS-CoV2 has even stirred uneasiness in patients, and physicians making diagnoses.

Beginning in Victorian-era England, a young boy presented to the doctor’s office with symptoms suggestive of scarlet fever; however, noticing heart disease in this child was just baffling. Despite being unaware of this rare disease, it was beyond physicians at the time; since then, progress has been limited as clinicians still fail to comprehend the disease’s root cause.

Dating back to 1874, KD was discovered by Samuel Gee while he was dissecting the cadaver of a seven-year-old boy.

He noticed something strange, “The pericardium was natural. The heart natural in size, and the valves healthy. The coronary arteries were dilated into aneurysms at three places, namely, at the apex of the heart a small aneurysm the size of a pea; at the base of the right ventricle, close to the tip of the right auricular appendix, and near to the mouth of one of the coronary arteries, another aneurysm of the same size; and at the back of the heart, at the base of the ventricles, and in the sulcus between the ventricles, a third aneurysm the size of a horse bean. These aneurysms contained small recent clots, quite loose. The aorta near the valves, and the aortic cusp of the mitral valve, presented specks of atheroma.

From his autopsy, evident was that Gee found aneurysms in the coronary arteries running across the surface of the boy’s heart. He then placed the specimen in a jar and provided it to the Barts Pathology Museum in London. Little did he know, that his specimen marked evidence of the earliest recorded case of KD and sparked worldwide medical curiosity. Unfortunately, when physicians 100 years later were hoping to retrieve samples from the specimen containing the boy’s heart, they were informed that it was missing.

A few years later, the disease was recognized in 1967 by the Japanese physician, Tomikasu Kawasaki. Although some researchers claimed the virus was unknown, others stated KD resulted from a bacterial or fungal toxin. The windborne theory suggested that the disease was seasonal, and as such, the direction of the swaying wind played a role in infection. Others stated that since children’s immune systems are still developing and since they have just lost the protective antibodies from their mothers, they are susceptible to infection. Therefore, in Asian American household’s diets rich in soy put Asian children at greater risk due to the isoflavones. In the 1980s, the Center for Disease Control and Prevention (CDC) suspected chemicals as the cause of KD, inferring that disease stems from agents that trigger an overreaction of the patient’s immune system. No one knew exactly what the mechanism or cause of KD was, although many scientists speculated some theories.

Over the last decade, significant progress toward understanding the pathogenesis, history, and therapeutic interventions of KD has been fruitful. Treatment aimed at the intravenous infusion of gamma globulin antibodies derived from the plasma of blood donations has helped children recover. In contrast, other therapies of corticosteroids for immunoglobulin-resistant patients and tumor inhibitors such as etanercept, infliximab, and cyclosporin A have been other medications providing relief.

The most significant clinical debate was over the possible link between the rash and the cardiac complications seen in Asian American children. Factors responsible for KD were introduced into Japan after World War II and re-emerged in a more virulent form spreading through the industrialized Western world. Advancements in medicine, improvements in healthcare, and, notably, the use of antibiotics reduced the burden of rash and fever illnesses significantly allowing KD to be recognized as a distinct clinical entity.

Nonetheless, the enigma pervades even during the COVID19 pandemic; this time, more pressing as the ever-elusive cause of KD that troubles children’s hearts affects physicians’ sleep and worries parents’ minds. Although the story of Kawasaki disease began decades ago when a young boy’s heart was locked inside a glass specimen, its ending is still being crafted. By the time the heart is found again at the museum, and placed safely for visitors treasuring ancient history, what further knowledge and progress will the scientific community have achieved? How far will humanity have come to find answers to KD and fill in the perplexing missing piece of the puzzle?

For now, there are no answers, but the enigma continues…

Cite this article as: Leah Sarah Peer, Canada, "The Kawasaki Disease Enigma Continues 150 years Later," in International Emergency Medicine Education Project, July 24, 2020, https://iem-student.org/2020/07/24/kawasaki-disease-enigma-continues/, date accessed: September 25, 2021

References and Further Reading

Is it just a viral disease?

is it just a viral disease - dengue

The world is scared of COVID19. Brazilian health professionals too. But today I bring something else that has haunted Brazil for years. It’s dengue. Even with the COVID19 pandemic, the mosquito Aedes aegipty doesn’t give us a break.

Dengue is an arbovirus of the flavivirus genus, which is transmitted by the Aedes aegypti mosquito, and has 4 well-established serotypes: DENV-1, DENV-2, DENV-3, and DENV-4.

Dengue is an infectious viral disease which causes a feverish syndrome. Only in January, February and March, there are 94,149 probable cases of dengue in Brazil. In 2019, there were 1,527,119 cases. The intense summer, high temperatures, and rain helped with the proliferation of the vector last year. And, there was also a change in the serotype. Dengue has 4 circulating serotypes. Here in Brazil, the most common had been 1 and 4; however, the circulation of serotype 2 increased – linked to greater severity and hemorrhage. We cannot concentrate all efforts on COVID19 and forget about some diseases that continue to attack our population.

Deaths from dengue are preventable, except for fulminating cases. Many deaths from dengue are consequences of an error, it may be the delay in seeking health care, the lack of access to the network, and the difficulty in identifying the seriousness of the cases.

The fight to stop the transmission of dengue requires a collective effort because it is transmitted by insects, and that is where exactly the Aedes aegypti mosquito, the great star of dengue, comes into play. The Aedes aegypti mosquito thrives in standing water. The female is responsible for carrying the dengue virus. In addition to dengue, this mosquito can transmit urban yellow fever, Zika, and Chikungunya.

dengue

Then, a patient with a high fever, retro-orbital pain, myalgia, prostration, headache, and maculopapular rash arrives and a recent trip to tropical regions (like Brazil!) … think, it could be dengue!

“As per WHO guideline 2009, dengue patients can be further categorized on the severity basis that includes severe dengue patients, dengue patients with few warning signs, and dengue patients with no warning signs. Dengue hemorrhagic fever which is most severe out of these three categories mainly occurs in 5% of total dengue patients”.(2)

Although there is a test called NS1 (viral antigen research) widely used in Brazil for the diagnosis of dengue, with a sensitivity of 70% and specificity of 95%, it is not a good test to rule out the suspicion of Dengue even if it comes negative – and this pattern is repeated in all the other methods like Viral Antigen Research (NS1), Genetic Amplification Test (RRT-PCR) and Tissue immunohistochemistry. It must be done until the 3rd day; after that, its accuracy drops a lot. Moreover, if the patient has had dengue before, its diagnostic value drops. (4)

Regardless of this issue of time, some tests valid for patients are blood count (presence of atypical lymphocytes and thrombocytopenia) and those that demonstrate organ dysfunction, such as TGO and TGP, urea and creatinine) to monitor the severity of the case and guide your treatment. Hemoconcentration, evidenced by the progressive increase in hematocrit (Ht) is the main laboratory finding in the identification of capillary leakage so it can show the severity of the patient.

Do not freak out! If your patient has no alarm signs and no special conditions, treatment can be done on an outpatient basis, advising the patient on the warning signs and the importance of hydration. There is no specific antiviral treatment available in the market yet. Generally, treatment includes the mechanism of controlling fever and pain with paracetamol rather than aspirin (aspirin may promote bleeding), and increasing fluid intake ³. (Look for the specific protocol of your country for the treatment of dengue). And avoid using medications that affect the coagulation cascade, such as non-steroidal anti-inflammatory and acetylsalicylic acid.

Staging and start hydrating!

You may be asking yourself, why do some people develop dengue more seriously and others don’t?

Halstead’s theory states that the disease is becoming more and more severe as the patient becomes infected with different serotypes of the causative virus.
The idea is that in the first infection, the organism can defend itself by producing a series of antibodies that are specific to that invading serotype. But if reinfection with another type of virus occurs, these antibodies may even bind to the pathogen, but they are not effective in stopping them. And this connection also favors the entry of viruses into cells, which enhances their multiplication and, consequently, the patient’s clinical condition.

This is the most accepted theory. There are others, such as the theory of multicausality, which claims the severity of the disease is associated with the interaction between several factors, ranging from the pathogen’s virulence to environmental conditions and also from the disease itself and patient being infected (such as previous comorbidities, age, among others).

Here in Brazil, we have a popular saying “It’s just a bug!”. We use it as a joke when we go to the doctor and he tells us: “it’s just a viral disease, go home, get hydrated and rest!” Yes, dengue is a viral disease. But it deserves special attention, as it can turn into a serious organ dysfunction if not treated properly !!

Cite this article as: Rebeca Rios, Brasil, "Is it just a viral disease?," in International Emergency Medicine Education Project, June 29, 2020, https://iem-student.org/2020/06/29/is-it-just-a-viral-disease/, date accessed: September 25, 2021

References

  1. https://www1.folha.uol.com.br/cotidiano/2020/01/brasil-registra-em-2019-segundo-maior-numero-de-mortes-por-dengue-em-21-anos.shtml
  2. Giang HT, Banno K, Minh LH, Trinh LT, Loc LT, Eltobgy A, et al. Dengue hemophagocytic syndrome: A systematic review and meta-analysis on epidemiology, clinical signs, outcomes, and risk factors. Rev Med Virol 2018; 28(6): e2005.  
  3. Rinku Rozera1, Surajpal Verma1, Ravi Kumar1, Anzarul Haque2, Anshul Attri1 Herbal remedies, vaccines and drugs for dengue fever: Emerging prevention and treatment strategies. Asian Pacific Journal of Tropical Medicine. 2019
  4. CRUZ, Jaqueline. Avaliação de Testes Diagnósticos para a Identificação da Infecção pelo Vírus da Dengue em Pacientes com Síndrome Febril Aguda. Dissertação (Mestrado em Biotecnologia em Saúde e Medicina Investigativa) – Fundação Oswaldo Cruz, Salvador, 2014.
  5. Ministério da Saúde. Dengue: Diagnóstico e Manejo Clínico. 5a ed. Brasília: Ministério da Saúde, 2016.

COVID-19 Clinical Readiness Course For Medical Students

COVID-19 clinical readiness course

Dear students,

We are pleased to open our fourth course for you; iEM/Lecturio – COVID-19 Clinal Readiness Course.

As we did in the EMCC course, we collaborated with Lecturio to provide you an excellent course to improve your knowledge in the clinical applications in COVID-19 cases.

The interactive course content is prepared by Lecturio’s expert educators Dr. Eisha Chopra, Dr. Julie Rice, Dr. Daniel Sweiden, Dr. Julianna Jung from John Hopkins University, Department of Emergency Medicine. Assessments of the course were prepared by Dr. Arif Alper Cevik from United Arab Emirates University, College of Medicine and Health Sciences.

One more time, we thank Lecturio for their amazing resources and support to our social responsibility initiative to help medical students in need during these challenging times.

As a part of our social responsibility initiative, iem-course.org will continue to provide free open online courses related to emergency medicine. We hope our courses help you to continue your education during these difficult times.

Please send us your feedback or requests about courses.

We are here to help you.

Best regards.

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

iEM Course is a social responsibility initiative of iEM Education Project

Course Length

This course requires 2-4 hours of study time. The course content will be available for 7 days after the enrolment.

Who can get benefit from this course?

  • Junior and senior medical students (course specifically designed for these groups)
  • Interns/Junior emergency medicine residents/registrars

Certificate

The candidates who successfully pass final summative assessment of the course will be provided course completion certificate.

Other Free Online Courses

Cite this article as: Arif Alper Cevik, "COVID-19 Clinical Readiness Course For Medical Students," in International Emergency Medicine Education Project, June 26, 2020, https://iem-student.org/2020/06/26/covid-19-clinical-readiness-course/, date accessed: September 25, 2021

Emergency Department Crowding: A conceptual model

Overcrowding is a serious problem in healthcare systems all around the world. In particular, Emergency Departments, which, by definition, deal with acute and unscheduled patients, are more susceptible to overcrowding. Even the parts of the world with developed hospital systems suffer from ED overcrowding, the burden is heavier in the developing world. Emergency department crowding is a significant barrier that prevents patients from receiving adequate and timely care.

Researchers of this field and policymakers had recognized the importance of the problem for ages, but COVID-19 pandemic highlighted it once again. Asplin et al’s conceptual model, published in Annals of Emergency Medicine in August 2003, continues to be relevant today and helps all stakeholders of emergency care -researchers, policymakers and administrators alike- to come up with sounding solutions. According to this conceptual model (See figure below) causes of ED overcrowding is divided into 3 independent components, namely, input causes, throughput causes and output causes.

At different times, multiple components occur to some extent in all acute care centres. This conceptual model provides an overview of overcrowding causes so that administrators may review what’s failing and develop more efficient emergency department operations and policies. Subsequently, it will help to reduce ED crowding. Also, learning how ED, as a workplace, works on an organizational level has the potential to increase medical graduates’ interest in research and policymaking, thus, feedback on system design from diverse stakeholders.

The input-throughput-output conceptual model of ED crowding adapted from Asplin et al. August 2003

Reference

  • Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA Jr. A conceptual model of emergency department crowding. Ann Emerg Med. 2003;42(2):173‐180. doi:10.1067/mem.2003.302
Cite this article as: Temesgen Beyene, Ethiopia, "Emergency Department Crowding: A conceptual model," in International Emergency Medicine Education Project, June 19, 2020, https://iem-student.org/2020/06/19/emergency-department-crowding-a-conceptual-model/, date accessed: September 25, 2021

COVID-19 and Hydroxychloroquine

Authors: Nardos Makkonen, MD and Amita Sudhir, MD
University of Virginia, USA

Life does not choose the logically best design to meet a new situation. It adapts what already exists...The result, unlike the clean straight lines of logic, is often irregular, messy.

John Barry

In The Great Influenza, The story of the Deadliest Pandemic in History, the author John Barry states, “Life does not choose the logically best design to meet a new situation. It adapts what already exists…The result, unlike the clean straight lines of logic, is often irregular, messy.” This has never been more evident than now as the way we practice medicine changes fundamentally in the face of a new pandemic. While the news of a novel coronavirus spread, many in the scientific community found themselves struggling to find answers. In the wake of the pandemic, multiple studies were published aiming to identify risk factors, disease progression, and most importantly, therapeutic options.

As the number of positive cases grew exponentially, so did the urgency to find an effective therapy. Scientists and medical professionals were tasked with finding a swift solution. In addition to vaccine development, trials looking at the effectiveness of previously existing antiviral medications against SARS-CoV-2 were underway. A number of in-vitro models showed promising results – existing antiviral and antimalarial medications, including Hydroxychloroquine and Remdesivir, were noted to have cytotoxic properties against the novel coronavirus (1, 2). At first, it was difficult to tell how this could shape the management of affected patients. Then came a study that would change the global conversation on COVID therapies.

covid19

An article published on March 20th in the International Journal of Antimicrobial Agents looked at the effect of hydroxychloroquine and azithromycin on COVID positive patients. The study was an open-label, non-randomized clinical trial of thirty-six patients; twenty patients were treated with hydroxychloroquine, while sixteen were in the control group. The article looked at SARS–CoV-2 clearance from the nasopharynx after six days. Higher frequency of viral clearance was reported in the treatment group, hydroxychloroquine (plus azithromycin if deemed necessary) versus an untreated control group [14 out of 20 (70%) vs. 2 out of 16 (13%); P < 0.001]. The authors concluded that the addition of azithromycin to hydroxychloroquine was significantly more efficient for virus elimination (3). Multiple articles were published that questioned various aspects of the original article. Nonetheless, the original excitement surrounding the medication led to its widespread use for treatment of COVID positive patients in various hospitals across the world. However, in the ensuing months, multiple additional studies have been published that have informed our understanding of hydroxychloroquine as a treatment option for SARS–CoV-2, suggesting that it may not be the panacea that the initial study suggested it is.

One of the first randomized control trials on the topic was a multicenter, open-label, randomized control trial looking at 150 patients. Seventy-five patients were assigned to hydroxychloroquine plus standard of care, while the other 75 were assigned to standard of care alone. The primary endpoint of this study was looking at viral clearance by 28 days. The results suggested hydroxychloroquine was not associated with a significantly higher probability of negative conversion than the standard of care alone (4). In another retrospective cohort study of 1438 patients hospitalized in metropolitan New York, treatment with hydroxychloroquine, azithromycin, or both did not result in a significantly lower in-hospital mortality (5). A meta-analysis looked at eleven studies, including three randomized controlled trials and eight observational studies. Here, 2354 patients received hydroxychloroquine alone or in combination, while 1952 did not. The study found no significant difference in clinical progression, mortality, or viral clearance by RT-PCR among patients with COVID-19 infection who are treated with hydroxychloroquine compared with control groups (6). In addition, a significantly higher incidence of adverse events associated with hydroxychloroquine use across a number of studies was noted.

Adverse effects were also noted in a multinational registry analysis of the use of hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19. The registry comprised data from 671 hospitals in six continents. The findings show no confirmed benefit of hydroxychloroquine or chloroquine when used alone or with a macrolide on in-hospital outcomes for COVID-19. Notably, each of these drugs was found to be associated with decreased in-hospital survival and increased frequency of ventricular arrhythmias (7). Importantly, the Lancet has since released a letter of concern on 6/2/20 regarding its publication of this multinational registry analysis (8).

Beyond its potential therapeutic use for known COVID positive patients, hydroxychloroquine was touted as beneficial for prophylactic use. Prior to the publication of significant studies on the prophylactic efficacy of the medication, the Indian Council of Medical Research, under the Ministry of Health and Family Welfare, recommended chemoprophylaxis with hydroxychloroquine for asymptomatic health-care workers treating patients with suspected or confirmed COVID-19, and for asymptomatic household contacts of confirmed cases. The announcement led some in the scientific community to express concern, stating “the drug is untested, the benefits unknown, and the risks not negligible” (9). This concern was substantiated in subsequent studies. A recent randomized, double-blind, placebo-controlled trial analyzed the effect of hydroxychloroquine in postexposure prophylaxis. The study included 821 asymptomatic participants. 87.6% of the participants (719 of 821) had a high-risk exposure to a confirmed COVID contact. The primary outcome was symptomatic illness confirmed by a positive molecular assay or, if testing is not available, COVID-related symptoms. The results noted no significant difference in the primary outcome between participants receiving hydroxychloroquine (49 out of 414 [11.8%]) and those receiving placebo (58 out of 407 [14.3%]) (10). Additionally, side effects were noted to be more common with hydroxychloroquine than with placebo (40.1% vs. 16.8%).

On May 27th, Dr. Anthony Fauci, the director of National Institute of Allergy and Infectious Diseases, when asked about hydroxychloroquine, stated that “The scientific data is really quite evident now about the lack of efficacy.” As of now, the World Health Organization is planning on resuming Hydroxychloroquine clinical trials after previously halting studies due to safety concerns (11). One adage often repeated in medicine is that what we learn now may not apply in 10 years. In the age of COVID, what we learn now may not apply in the next few months or even weeks. Seeing images of ventilated patients, and at times dead bodies across hospital hallways have filled us all with a deep desire for a quick fix. As physicians, we are likely to grasp at any straws that might help us fight this disease; we have to be careful to look critically at the evidence. Hope springs for a cure with each new study, but we should apply the same rigorous scientific methodology to COVID that we have developed for other diseases. As we move towards alleviating the suffering of this pandemic, it is essential to avoid falling into pitfalls and causing more harm along the way.

References and Further Reading

  1. Wang M, Cao R, Zhang L, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res. 2020;30(3):269-271.
  2. Liu J, Cao R, Xu M, et al. Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro. Cell Discov. 2020;6:16.
  3. Gautret P, Lagier JC, Parola P, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020;:105949.
  4. Tang W, Cao Z, Han M, et al. Hydroxychloroquine in patients with mainly mild to moderate coronavirus disease 2019: open label, randomised controlled trial. BMJ. 2020;369:m1849.
  5. Rosenberg ES, Dufort EM, Udo T, et al. Association of Treatment With Hydroxychloroquine or Azithromycin With In-Hospital Mortality in Patients With COVID-19 in New York State. JAMA. 2020;
  6. Chacko J, Brar G, Premkumar R. Hydroxychloroquine in COVID-19: A systematic review and meta-analysis. 2020. doi:10.1101/2020.05.14.20101774
  7. Mehra MR, Desai SS, Ruschitzka F, Patel AN. Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis. The Lancet. 2020. doi:10.1016/s0140-6736(20)31180-6.
  8. Editors TL. Expression of concern: Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis. The Lancet. 2020. doi:10.1016/s0140-6736(20)31290-3.
  9. Rathi S, Ish P, Kalantri A, Kalantri S. Hydroxychloroquine prophylaxis for COVID-19 contacts in India. Lancet Infect Dis. 2020;
  10. Boulware DR, Pullen MF, Bangdiwala AS, et al. A Randomized Trial of Hydroxychloroquine as Postexposure Prophylaxis for Covid-19. N Engl J Med. 2020;
  11. BerkeleyJr. World Health Organization resumes coronavirus trial on malaria drug hydroxychloroquine after examining safety concerns. CNBC. https://www.cnbc.com/2020/06/03/world-health-organization-resumes-coronavirus-trial-on-malaria-drug-hydroxychloroquine-after-safety-concerns.html. Published
Cite this article as: Amita Sudhir, USA, "COVID-19 and Hydroxychloroquine," in International Emergency Medicine Education Project, June 15, 2020, https://iem-student.org/2020/06/15/covid-19-and-hydroxychloroquine/, date accessed: September 25, 2021